Diagnostic value of four-dimensional computed tomography and four-dimensional magnetic resonance imaging in primary hyperparathyroidism when first-line imaging was inadequate.

INTRODUCTION: Accurate localisation of the abnormal hyperfunctioning gland with preoperative imaging has a critical role in parathyroid surgery to obtain a successful outcome. This study aimed to evaluate the diagnostic performance of second-line imaging and their contribution to the treatment success in primary hyperparathyroidism when the first-line methods were negative or discordant. METHODS: Among the patients who underwent parathyroidectomy due to primary hyperparathyroidism, 33 who underwent four-dimensional computed tomography and/or four-dimensional magnetic resonance imaging because of negative or discordant first-line imaging results were included. Persistent and recurrent cases were excluded. RESULTS: The majority of the patients were female (84.8%) and the mean age was 59.2 years. Seventeen patients had four-dimensional computed tomography and 25 had four-dimensional magnetic resonance imaging, respectively. Four-dimensional computed tomography and four-dimensional magnetic resonance imaging localised the culprit gland successfully in 52.9% and 84%, respectively. Twenty-five patients in whom single adenoma was detected underwent focused parathyroidectomy. The culprit gland was solitary in 32 cases and one patient had double adenoma. Normocalcaemia was achieved in all cases. Among the 29 patients who completed their postoperative sixth month success rate was 100%. CONCLUSION: Four-dimensional magnetic resonance imaging had high accuracy with fast dynamic imaging in detecting parathyroid adenomas. When the first-line imaging methods were negative or inconclusive, four-dimensional magnetic resonance imaging should be considered primarily since it is cost effective in Turkey and emits no radiation.

A comparison of the diagnosis of gastroparesis in 4 h pediatric gastric emptying studies versus 2 h studies.

BACKGROUND: In adults, there is a consensus for standards to diagnose gastroparesis utilizing a gastric emptying study as the key diagnostic modality but there is no consensus for a standard in pediatrics. Additionally, some cost savings might be achieved if symptoms could be utilized to predict patients with gastroparesis. The aims of the current study were to confirm the sensitivity of a 4 h study in the pediatric population and to assess whether the severity of symptoms were predictive of delayed gastric emptying. STUDY: This was a single site, two part study. In the first part, results were reviewed for all patients who had completed a 4-h, solid gastric emptying study over the course of a 3 year period. In the second portion of the study, participants scheduled for a gastric emptying study, completed a modified GCSI questionnaire. RESULTS: Out of a total of 109 participants, at 2 h, 14 participants (12.8%) had abnormal studies as compared to 26 (23.85%) participants who had abnormal studies at 4 h (p = .0027). Of the 95 participants with normal studies at 2 h, 15% (14/95) were abnormal at 4 h. There were no differences in symptom severity scores between those with slow and those with normal emptying at either 2 h or 4 h. CONCLUSIONS: Our study adds independent confirmation that extending studies from 2 to 4 h increases the diagnostic yield and should be the standard in children and adolescents as it is in adults.

Cost burden of neuroimaging during one-time admission for first-ever acute stroke in Nigeria.

OBJECTIVE: To determine the cost burden of Neuroimaging and its contribution to direct total hospitalization costs (HCs) during one-time admission for first-ever stroke. METHODS: The clinical characteristics, direct itemised costs and total HCs for 170 consecutive patients with first-ever stroke, admitted at our public tertiary health facility over a 15-month period were evaluated. RESULTS: The records of 170 stroke subjects were reviewed. The median total HCs for one-time admission per stroke patient was $183.30 with a median daily cost of $15.86. Median cost of radiological investigations was the highest among the categorized hospital costs. Among the radiological investigations, neuroimaging accounted for at least 99% of cost to patients. CONCLUSION: The financial burden of radiological investigations, particularly neuroimaging, is high during one-time admission of patients with first-ever stroke in our environment.

Is TSH necessary for initial assessment of thyroid nodules?

OBJECTIVE: The use of thyrotropin (TSH) in the initial assessment of thyroid nodules is inefficient and leads to unnecessary assessment costs. We compared the total costs of thyroid nodule assessment with or without the use of TSH in the initial assessment. METHODS: A total of 1808 patients with thyroid nodules received TSH, fine-needle aspiration (FNA) and thyroid scintigraphy (TS) assessment, including 83 autonomously functioning thyroid nodule (AFTN) cases and 1725 non-AFTN cases. The total costs of the TSH strategy and non-TSH strategies were compared. The ratio of single-use costs of FNA to TS (CFNA/TS ) was used as the main outcome measure. RESULTS: Only when 6·03 ≤ CFNA/TS ≤ 27·17, the lowest total costs were associated with using the conventional TSH strategy. When CFNA/TS <6·03 or CFNA/TS >27·17, the lowest costs were found with FNA and TS, respectively. CONCLUSION: From the perspective of cost economics, in iodine-sufficient areas, we recommend that the decision on the use of TSH for the initial assessment of thyroid nodules should be based on the testing costs of FNA and TS in that medical unit.

Preoperative Sentinel Node Mapping in Sentinel Node Biopsy in Early Breast Cancers - Is It Cost-Effective?

INTRODUCTION: Sentinel lymph node (SLN) biopsy is currently the gold standard of treatment in early breast cancers. Identification of SLNs by preoperative scintigraphy has been carried out to improve the detection of SLNs intraoperatively, but the evidence of its cost-effectiveness is lacking. Here, we analyze the cost-effectiveness of the utilization of scintigraphy in detection of SLNs. PATIENTS AND METHODS: Clinical and operative details were retrieved from a prospectively maintained database. The resources and cost data from each patient who had undergone SLN biopsy with preoperative scintigraphy were retrieved. RESULTS: From January 2008 to December 2012, 400 patients underwent SLN biopsy for breast cancer. A total of 329 had preoperative SLN mapping with scintigraphy, Baseline patient demographic data for both arms were comparable. The relapse and recurrence rate of both arms were not statistically different. The detection rate of SLNs of both arms was the same (100%), and there were no grade 2 or above lymphedema in both groups of patients. However, the cost of each patient undergoing SLN mapping was USD $345.8. CONCLUSION: Preoperative SLN mapping does not improve the SLN detection rate. In addition, it does not affect the surgical outcomes in terms of complication, local relapse, and recurrence. The use of preoperative SLN mapping is no longer cost-effective.

Cost and radiation exposure in the workup of febrile pediatric urinary tract infections.

BACKGROUND: Technetium-99m dimercaptosuccinic acid (DMSA) scans are often used in the evaluation of pediatric patients with febrile urinary tract infections (UTIs). Given the prevalence of febrile UTIs, we sought to quantify the cost, radiation exposure, and clinical utility of DMSA scans when compared with dedicated pediatric renal ultrasounds (RUSs). MATERIALS AND METHODS: An institutional review board approved retrospective study of children under the age of 18 years evaluated at our institution for febrile UTIs between the years 2004-2013 was conducted. The patients had to meet all of the following inclusion criteria: a diagnosis of vesicoureteral reflux, a fever >38°C, a positive urine culture, and evaluation with a DMSA scan and RUS. A chart review was used to construct a cost analysis of technical and professional fees, radiographic results, and radiation dose equivalents. RESULTS: Overall, 104 children met the inclusion criteria. A total of 122 RUS and 135 DMSA scans were performed. The technical costs of a DMSA scan incurred a 35% cost premium as compared to an RUS. The average effective radiation dose of a single DMSA scan was 2.84 mSv. New radiographic findings were only identified on 7% of those patients who underwent greater than 1 DMSA scan. CONCLUSIONS: The utility of the unique information acquired from a DMSA scan as compared to a RUS in the evaluation of febrile UTI must be evaluated on an individual case-by-case basis given the increased direct costs and radiation exposure to the patient.

Cost-Savings Analysis of Renal Scintigraphy, Stratified by Renal Function Thresholds: Mercaptoacetyltriglycine Versus Diethylene Triamine Penta-Acetic Acid.

PURPOSE: To determine the financial implications of switching technetium (Tc)-99m mercaptoacetyltriglycine (MAG-3) to Tc-99m diethylene triamine penta-acetic acid (DTPA) at certain renal function thresholds before renal scintigraphy. METHODS: Institutional review board approval was obtained, and informed consent was waived for this HIPAA-compliant, retrospective, cohort study. Consecutive adult subjects (27 inpatients; 124 outpatients) who underwent MAG-3 renal scintigraphy, in the period from July 1, 2012 to June 30, 2013, were stratified retrospectively by hypothetical serum creatinine and estimated glomerular filtration rate (eGFR) thresholds, based on pre-procedure renal function. Thresholds were used to estimate the financial effects of using MAG-3 when renal function was at or worse than a given cutoff value, and DTPA otherwise. Cost analysis was performed with consideration of raw material and preparation costs, with radiotracer costs estimated by both vendor list pricing and proprietary institutional pricing. The primary outcome was a comparison of each hypothetical threshold to the clinical reality in which all subjects received MAG-3, and the results were supported by univariate sensitivity analysis. RESULTS: Annual cost savings by serum creatinine threshold were as follows (threshold given in mg/dL): $17,319 if ≥1.0; $33,015 if ≥1.5; and $35,180 if ≥2.0. Annual cost savings by eGFR threshold were as follows (threshold given in mL/min/1.73 m(2)): $21,649 if ≤60; $28,414 if ≤45; and $32,744 if ≤30. Cost-savings inflection points were approximately 1.25 mg/dL (serum creatinine) and 60 mL/min/1.73m(2) (eGFR). Secondary analysis by proprietary institutional pricing revealed similar trends, and cost savings of similar magnitude. Sensitivity analysis confirmed cost savings at all tested thresholds. CONCLUSIONS: Reserving MAG-3 utilization for patients who have impaired renal function can impart substantial annual cost savings to a radiology department.

Comparison of SPECT/CT and planar MIBI in terms of operating time and cost in the surgical management of primary hyperparathyroidism.

We conducted a retrospective study to compare operating times and costs in patients who underwent guided parathyroidectomies with either (1) technetium-99m ((99m)Tc) multiplex ion-beam imaging (MIBI) parathyroid scintigraphy with single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images or (2) sestamibi dual-phase (99m)Tc MIBI planar parathyroid scintigraphy alone preoperatively. Our study population was made up of the first 24 patients at our facility who had undergone SPECT/CT parathyroid imaging with technetium-99m ((99m)Tc) MIBI and a group of 24 patients who had undergone MIBI planar imaging alone. Patient demographics, preoperative laboratory test results, operating times, and hospital charges were analyzed. We found that less operating time was required for the planar MIBI group than in the SPECT/CT group (mean: 135 vs. 158 min), although the difference was not statistically significant. Likewise, the total cost of treatment was lower in the planar MIBI group (mean: $10,035 vs. $11,592); the difference was statistically significant by one measure (p × 0.02, Wilcoxon rank sum test) but not by another (p × 0.06, Student t test). Although SPECT/CT is efficient for patients with small and difficult-to-localize adenomas, it has yet to demonstrate greater efficacy or cost-effectiveness than planar MIBI for routine parathyroidectomy in patients with primary hyperparathyroidism when an easily identifiable parathyroid adenoma is localized.

Overutilization and Cost of Advanced Imaging for Long-Bone Cartilaginous Lesions.

BACKGROUND: The prevalence and cost of unnecessary advanced imaging studies (AIS) in the evaluation of long bone cartilaginous lesions have not been studied previously. METHODS: A total of 105 enchondromas and 19 chondrosarcomas arising in long bones from July 2008 until April 2012 in 121 patients were reviewed. Advanced imaging was defined as MRI, CT, bone scan, skeletal survey, or CT biopsy. Two blinded radiologists independently reviewed the initial imaging study and determined if further imaging was indicated based on that imaging study alone. The cost of imaging was taken from our institution's global charge list. Imaging was deemed unnecessary if it was not recommended by our radiologists after review of the initial imaging study. The difference in cost was calculated by subtracting the cost of imaging recommended by each radiologist from the cost of unnecessary imaging. The sensitivity and specificity for distinguishing enchondromas from chondrosarcomas was calculated. A minimum of 2 years from diagnosis of an enchondroma was required to monitor for malignant transformation. RESULTS: Of patients diagnosed with an enchondroma, 85 % presented with AIS. The average enchondroma patient presented with one unnecessary AIS. The radiologists' interpretations agreed 85 % of the time for enchondromas and 100 % for chondrosarcomas. The sensitivity and specificity for distinguishing enchondromas from chondrosarcomas was 95 % for one radiologist and 87 and 95 % for the other. The average unnecessary cost per enchondroma patient was $1,346.18. CONCLUSIONS: Unnecessary AIS are frequently performed and are a significant source of expense. The imaging algorithms outlined in this study may reduce unnecessary AIS.

Bone scintigraphy in axial seronegative spondyloarthritis patients: role in detection of subclinical peripheral arthritis and disease activity.

AIM: To detect subclinical peripheral arthritis and disease activity in axial seronegative spondyloarthritis (SpA) patients using bone scintigraphy. METHODS: Seronegative SpA patients with an established diagnosis and no clinically evident arthritis at the time of the study were included. After excluding symptomatic cases, 20 patients were recruited; 18 with ankylosing spondylitis (AS) and another two with psoriatic arthritis (PsA). Conventional bone scintigraphy was performed to detect the distribution of increased uptake, blood vascular pool (vascularity) and activity. RESULTS: The peripheral joints in all the patients were asymptomatic with no signs of arthritis on clinical examination. Disease activity was higher in those with hypervascularity and activity (75%) detected by scintigraphy. Scintigraphic activity of the sacroiliac joints was found in 10 patients (50%) with a mean sacroiliac joint index of 2.4 ± 0.6. Subclinical involvement of the hips, knees, shoulders, ankles, small joints of the hands, ankles and sternoclavicular joints, as well as the small joints of the feet were detected with descending frequencies (25%, 25%, 20%, 20%, 15%, 10% and 10%, respectively). Dorsal spine increased uptake was found in 35% and hypervascularity of the skull in two cases. Avascular necrosis of the hip was present in one case with hypovascularity. CONCLUSION: The spectrum of joint involvement in seronegative SpAs should not be limited to sacroiliitis. Bone scintigraphy provides a cost-effective method for detecting the extent of involvement in this group of autoimmune systemic diseases (axial SpA) without clinical evidence of peripheral arthritis.

Investigation Route of the Coronary Patient in the Public Health System in Curitiba, São Paulo and in Incor - IMPACT Study / Itinerário de Investigação do Paciente Coronariano do SUS em Curitiba, São Paulo e Incor - Estudo IMPACT

Background: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. Objective: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. Methods: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. Results: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. Conclusion: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS. .

Fundamento: A investigação da doença arterial coronariana (DAC) estável e seu tratamento dependem da estratificação de risco para a decisão sobre a necessidade de cateterismo cardíaco e revascularização. Objetivo: Analisar os procedimentos utilizados no diagnóstico e tratamento invasivo dos pacientes com DAC do Sistema Único de Saúde (SUS) nos municípios de Curitiba, São Paulo e no IIncor- FMUSP. Métodos: Estudo retrospectivo, descritivo, observacional dos itinerários diagnósticos e terapêuticos dos pacientes do SUS, entre os grupos submetidos ou não a testes não invasivos prévios ao cateterismo cardíaco invasivo. Foram quantificados os procedimentos de teste ergométrico, ecocardiograma de estresse, cintilografia de perfusão, cateterismo e tratamento com revascularização percutânea ou cirúrgica e o impacto econômico destas estratégias utilizadas. Resultados: Existem diferenças importantes na avaliação do paciente com DAC suspeita ou conhecida nos três cenários. Apesar dos testes funcionais serem os procedimentos mais frequentemente utilizados, os custos diretos referentes a esses procedimentos diferem significativamente (6,1% em Curitiba, 20% em São Paulo e 27% no Incor-FMUSP). Os custos relacionados aos procedimentos e tratamentos invasivos representam 59,7% dos custos diretos do SUS em São Paulo e 87,2% em Curitiba. No Incor-FMUSP, apenas 24,3% dos pacientes com DAC estável submetidos à revascularização foram submetidos a um teste não invasivo antes do procedimento. Conclusão: Apesar dos testes funcionais não invasivos serem os exames mais frequentemente solicitados na avaliação de pacientes com DAC suspeita ou conhecida, a maior parte dos custos está relacionada a procedimento/tratamento ...

Investigation route of the coronary patient in the public health system in Curitiba, São Paulo and in InCor--IMPACT study.

BACKGROUND: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. OBJECTIVE: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. METHODS: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. RESULTS: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. CONCLUSION: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Impact of provider-led, technology-enabled radiology management program on imaging.

OBJECTIVE: The study objective was to assess the impact of a provider-led, technology-enabled radiology medical management program on high-cost imaging use. METHODS: This study was performed in the ambulatory setting of an integrated healthcare system. After negotiating a risk contract with a major commercial payer, we created a physician-led radiology medical management program to help address potentially inappropriate high-cost imaging use. The radiology medical management program was enabled by a computerized physician order entry system with integrated clinical decision support and accountability tools, including (1) mandatory peer-to-peer consultation with radiologists before order completion when test utility was uncertain on the basis of order requisition; (2) quarterly practice pattern variation reports to providers; and (3) academic detailing for targeted outliers. The primary outcome measure was intensity of high-cost imaging, defined as the number of outpatient computed tomography (CT), magnetic resonance imaging (MRI), and nuclear cardiology studies per 1000 patient-months in the payer's panel. Chi-square test was used to assess trends. RESULTS: In 1.8 million patient-months from January 2004 to December 2009, 50,336 eligible studies were performed (54.1% CT, 40.3% MRI, 5.6% nuclear cardiology). There was a 12.0% sustained reduction in high-cost imaging intensity over the 5-year period (P < .001). The number of CT studies performed decreased from 17.5 per 1000 patient-months to 14.5 (P < .01); nuclear cardiology examinations decreased from 2.4 to 1.4 (P < .01) per 1000 patient-months. The MRI rate remained unchanged at 11 studies per 1000 patient-months. CONCLUSION: A provider-led radiology medical management program enabled through health information technology and accountability tools may produce a significant reduction in high-cost imaging use.

Diagnostic evaluation in patients with intractable epilepsy and normal findings on MRI: a decision analysis and cost-effectiveness study.

BACKGROUND AND PURPOSE: Patients with focal intractable epilepsy and normal MR imaging findings frequently undergo further diagnostic tests to localize the epileptogenic zone. The aim of this study was to determine the cost-effective diagnostic strategy that will identify the epileptogenic zone in patients with suspected focal intractable epilepsy and normal MR imaging findings by using decision analysis. MATERIALS AND METHODS: A Markov decision model was constructed by using sensitivities and specificities of test strategies, seizure outcomes following surgical and medical treatment, cost, utilities, probabilities, and standardized mortality ratios. We compared 6 diagnostic test strategies: PET, ictal SPECT, and MEG individually; and combinations of PET+SPECT, PET+MEG, and SPECT+MEG. The outcomes measured were health care costs, QALY, and ICER. One-way and probabilistic sensitivity analyses were conducted to adjust for uncertainties in model parameters. RESULTS: The preferred strategies were PET+MEG and SPECT. The health care cost of the baseline strategy (PET+MEG) was $95,612 with 16.30 QALY gained. SPECT cost $97,479 with 16.45 QALY gained and an ICER of $12,934/QALY gained compared with those in PET+MEG. One-way sensitivity analyses showed that the decisions of the model were sensitive to variations in sensitivity and specificity of the test strategies. Probabilistic sensitivity analysis showed that when the willingness to pay was <$10,000, PET+MEG was the favored strategy, but the favored strategy changed to SPECT when the willingness to pay was >$10,000. CONCLUSIONS: PET+MEG and SPECT were the preferred strategies in the base case. The choice of test was dependent on the sensitivity and specificity of test strategies and willingness to pay. Further study with a larger sample size is needed to obtain better estimates of sensitivity and specificity of diagnostic tests.

Gastroparesis in children: the benefit of conducting 4-hour scintigraphic gastric-emptying studies.

BACKGROUND AND AIM: Scintigraphic gastric emptying study (GES) is the criterion standard for diagnosis of gastroparesis. Adult studies demonstrated that extending GES to 4 hours increases its ability to diagnose delayed gastric emptying. Most pediatric centers assess GES up to 2 hours postmeal. The aim of the present study was to assess the effect of extending GES from 2 to 4 hours in evaluation of children with suspected gastroparesis. METHODS: We conducted a chart review of all children who had a 4-hour GES with standard radiolabeled solid meal in 2009-2010. Results of GES at 1, 2, and 4 hours were compared. Patients were diagnosed as having gastroparesis using adult criteria: if gastric retention of meal was >90%, 60%, and 10% at 1, 2 and 4 hours, respectively. A telephone survey assessed GES time at top 20 pediatric gastroenterology centers in the United States. Cost of evaluation of patients diagnosed as having gastroparesis was estimated. Full-time equivalents of nuclear medicine technicians and number of nuclear medicine studies done at Ann & Robert H. Lurie Children's Hospital of Chicago from 2007 to 2010 were examined. RESULTS: A total of 71 patients (32 boys, average age 10.8 years) were studied. Sixty-two percent (n=44) children had abnormal GES; 23% (8/35) of them who had normal values at 2 hours had abnormal GES at 4 hours (P<0.0001). Twenty-eight percent of patients had delayed GES at 1 hour: all persisted to have abnormal GES at 2 and 4 hours. Cost of evaluation of a child for gastroparesis was $9014. Only 5 of the top 20 pediatric gastroenterology centers in the United States conducted 4-hour GES. Transitioning from 2 hours to 4 hours only required scheduling adjustments and did not result in limitation in the number of scheduled patients. CONCLUSIONS: Extending GES to 4 hours results in a considerable increase in diagnosis of gastroparesis.

Advancing gastric emptying studies: standardization and new parameters to assess gastric motility and function.

For many years, gastric emptying (GE) studies were performed using various local protocols and different radiolabeled meals. This lack of standardization and normal values made the test results unreliable and difficult to compare from one site to another. A recent consensus has been published that now provides guidance and standardization on how to perform a radiolabeled solid-meal GE study. It is widely recognized, however, that simple measurement of total GE of a solid meal often does not provide an answer to the etiology of symptoms for a large number of patients who present with functional dyspepsia. Advances in our understanding of the different roles of the fundus and antrum and their complex interaction with the proximal small bowel and central nervous system have led to the development of new methods to study gastric motility. This review describes how a more comprehensive approach to studying GE is needed and how this will lead to better diagnosis and treatment for patients referred for GE studies.

[Cost of screening for hepatocarcinoma in patients with cirrhosis: a prospective study]. / Coste del cribado del hepatocarcinoma en pacientes cirróticos: un estudio prospectivo.

INTRODUCTION: Current clinical guidelines recommend biannual screening for hepatocarcinoma in cirrhotic patients; however, the cost of this preventive activity is unknown. OBJECTIVE: To determine the cost of ultrasound screening for hepatocarcinoma in patients with cirrhosis. PATIENTS AND METHOD: Data on patients diagnosed with liver cirrhosis in a population of 245,042 inhabitants were prospectively gathered. The screening tests performed and cases of hepatocarcinoma diagnosed during the annual follow-up were included in the analysis. The cost of these tests was calculated based on the tariffs paid by insurance companies for health coverage of civil servants. RESULTS: In 2009, there were 374 patients with cirrhosis; of these, 99 were aged > 80 years, with a performance status of >2 or associated comorbidities. During the annual follow-up, the remaining patients underwent a total of 602 visits (abdominal ultrasound, blood test), four contrast-enhanced computed tomography scans, nine magnetic resonance scans, two scintigraphies, four aspiration biopsies, four radiographs and six contrast ultrasound scans. In our environment, the total estimated cost of these procedures was 37,946 €, indicating that the cost of a screening program for hepatocellular carcinoma according to the above-mentioned selection criteria is 0.155 € per inhabitant/year. If only cirrhotic patients suitable for screening are included, the annual cost of screening is 138 € per patient. CONCLUSION: The cost of an ultrasound screening program for hepatocarcinoma is 0.155 € per inhabitant/year. These data should be taken into account when considering population-based screening programs.